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General Insurance Authorization info for ABA

January 30, 2013 Leave a comment

ABATrumpet Behavioral Health (TBA) and TACA (Talking about Curing Autism)  recently held a webinar about gaining insurance coverage for ABA (Applied Behavioral Analysis). ABA has typically been a 40 hr/week program at home aimed and infants and toddlers to train children in correct behavior.   It is not based on deep cognition.  Nonetheless it is one of the few things studied that have been shown to help autism, and what’s new is that insurance companies are beginning to cover it!    You can imagine  that any intervention  of 40 hrs/week with trained individuals can get quite expensive.

Important General Insurance Info

Regulating Health Plans in CA

TBA is based in California so there will be a California-centric view. In CA these are the organizations which regulate health plans: DMHC (Department of Managed Health Care) and CDI (California Division of Insurance).  If you have been denied healthcare these agencies can review the determination and may overturn insurance decisions.  They cannot change any benefits in the plan, but if the benefits are already in the plan they may be able to help you get them.

In your state, you might be able to go to the analogous agency in your state.  To find out who regulated insurance in your state you can simply ask the insurance company, and of course look it up on the web.

Type of Insurance Plan

  • Fully Insured – large group plans, regulated by the government, owned by insurance companies, regulated by state agencies.
  • Self Funded – employers money funds the plan so government mandates do not apply.  They may still hhave 3rd party administrators that look like insurance companies like the Fully Insured but employers decide final benefits. Several self insured plans cover ABA, such as Microsfot Home Depot etc

A Summary Plan Description- has the details of your plan, research this for benefit  actual benefit determination

Authorization

ABA falls under Mental Health benefit, therefore use mental health phone number when contacting the insurance company/administrator.  Your plan may have Autism Unit/Care Manager.  The best way to get authorization is to get a precise list of what documents are needed for authorization.

Assessment

ABA or any therapy requires an assessment.  You will want to find out what details are required to gain coverage.  Question can be:

  1. Who can do assesment?  Masters Level clincian? Licensed? How many hours after their masters are required i any?
  2. How long is the assessment? # of hours?  Are there different coverages for the assessment and the writeup for the assessments?  Is there a maximum timeperiod during which the report can be submitted?
  3. When is reassessment required?
  4. What code will you bill under?
  5. What assessemnt tools used by provider are approved?

Supervision

  1. Who can provide supervision? Masters? BCBA Licensed?
  2. Can Supervision be billed on same day as direct ABA Service?
  3. How many hours of supervision is approved?
  4. Does supervision have to be in presence of client?

Direct Services

  1. How many hours of direct therapy are covered?
  2. Who can provide direct therapy?
  3. Where can services be provided (historically it was at home), if clinic setting is there a different copay?
  4. What are approved dates of service?

Treatment Plan Requirements

  1. What forms should be used for authorization? Are they found online?
  2. Resend treatment plan before authorization expires?
  3. What to include in the treatment plan to be covered?
    • goals
    • objecives
    • target dates
    • baseline
    • transition plan
    • discharge criteria
    • Parent Involvement

How TBA can Help

Members of this organization fight for coverage under your exsiting coverage, they have several years of experience with  insurance companies, and state organizations.  They can help with the following to get coverage:

  • coding,
  • copay/ # of sessions
  • authorizations and
  • billing
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